What Patients Should Know About Out-of-Network Dental Insurance
Dental insurance often promises clear coverage, but recent legal action suggests the reality may be far more complicated. A 2026 lawsuit highlights how out-of-network benefits may be calculated using undisclosed internal pricing—leaving patients with unexpected costs. This article explains what patients should know, why transparency matters, and how thoughtful, long-term dental planning fits into the picture.
Out-of-network dental insurance usually still pays something toward your care, but often not the percentage of your dentist's fee that you might expect. Many plans apply their coverage percentage to their own allowed amount, a price the insurer sets, rather than to the fee your dentist charges. You are responsible for the difference, along with any deductible and anything above your annual maximum. Knowing how your plan calculates benefits before treatment starts helps avoid surprises.
What is an allowed amount?
An allowed amount is the price your plan decides to recognize for a given procedure. Plans may call it a maximum allowable charge, a usual and customary fee or something similar. When a plan says it covers 80% of a filling, it may mean 80% of its own allowed amount. If the allowed amount is lower than your dentist's fee, the plan pays less than you might expect, and the remaining balance is yours.
Most dental plans also have an annual maximum, the most the plan will pay in a plan year. Once you reach it, the plan pays nothing more until the next plan year.
What is the Delta Dental lawsuit about?
In January 2026, ADA News reported on a proposed class-action lawsuit filed by patients against Delta Dental entities in federal court in New York. The suit alleges that Delta Dental told members their plans would cover a stated percentage of out-of-network care, but calculated payments from an internal price that it did not disclose, leaving patients with larger balances than they expected.
These are allegations. When this post was updated in October 2026, the case was still open and the court had not decided whether the claims have merit. You can read the ADA News report.
Whatever the outcome, the case highlights a question every patient can ask: how exactly does my plan calculate what it pays?
What does out-of-network mean at our office?
We are an out-of-network practice. We can help you understand how to use your benefits. You are responsible for amounts your plan does not pay.
Your insurance may still contribute to your care when you see an out-of-network dentist. What it contributes depends on your plan's rules, not on our fees. Many patients with complex or medically involved needs want treatment planned around their health first and their benefits second. You can read more about complex and medically involved care.
What should I ask my plan before treatment?
Does my plan cover out-of-network dentists, and at what percentage?
Is that percentage applied to the dentist's fee or to the plan's allowed amount?
Will the plan tell me its allowed amount for a specific procedure before treatment?
What is my deductible, my annual maximum and how much of it have I used?
Are there waiting periods, frequency limits or exclusions that apply to my treatment?
Write down the answers and the date of the call. Plans change, and so do allowed amounts.
Planning care with insurance in mind
The right treatment depends on your mouth and your health, not on your plan's rules. Insurance still matters to most families, though, and it is reasonable to plan timing around it when that is clinically safe. If your plan year ends soon, see whether unused dental benefits expire at the end of the year. If you are planning for retirement or a change in coverage, read about retirement and dental insurance. New patients start with a comprehensive dental exam. See our new-patient information, or call our Jacksonville office at 904-398-1549.
Sources
ADA News. Patient lawsuit alleges Delta Dental misrepresents out-of-network coverage. January 2026. Retrieved October 6, 2026.
Walsh v. Delta Dental Plans Association et al., No. 1:25-cv-10801 (S.D.N.Y., filed December 31, 2025). Docket summary via PacerMonitor. Retrieved October 6, 2026.
About the author. CJ Henley, DMD, is a general dentist in Jacksonville whose practice focuses on cosmetic and restorative dentistry, dental implants and dental care around head and neck cancer. Meet Dr. Henley.
CJ Henley, DMD, PA · 3675 Hendricks Avenue, Jacksonville, FL 32207 · 904-398-1549
Updated October 2026.
Do Unused Dental Benefits Expire at the End of the Year?
When it comes to dental benefit plans, millions of people each year are ringing in the New Year leaving money on the table. According to the National Association of Dental Plans, only 2.8% of people with PPO dental plan participants reached or exceeded their plans annual maximum. Many people also have Flexible Spending Accounts, which help pay for dental and medical care with pre-tax dollars.
For most dental plans, yes. Your annual maximum resets when the plan year ends, often December 31, and unused benefits usually do not roll over. Money in a health flexible spending account (FSA) is also lost at the end of the plan year unless your employer offers a carryover of up to $680 for 2026 plan years or a grace period of up to two and a half months. Check your own plan's dates, and let your dental needs, not the calendar, decide what treatment you have.
When does my dental plan year end?
Many dental plans run on the calendar year, but some follow a different 12-month cycle tied to your employer's benefits year. Your plan document, your benefits office or the member services number on your insurance card can tell you:
when your plan year ends
how much of your annual maximum you have used
whether any treatment has a waiting period or frequency limit
How can I make the most of my dental plan?
Keep up with checkups and cleanings. Many plans cover routine exams and cleanings at a higher level than other treatment. Check your plan for the exact coverage.
Plan in the summer or early fall. If a checkup shows that you need treatment, ask about timing then. Appointments fill quickly in November and December.
Let the clinical need set the schedule. Some treatment can safely be staged across two plan years, and some should not wait. I will tell you which is which. A benefit deadline is never a good reason to start treatment you do not need.
How do FSAs work for dental care?
A health FSA is an account you set up through your employer. You choose an amount during open enrollment, and it is taken from your paychecks before taxes. For plan years beginning in 2026, the IRS limit is $3,400 per employee.
FSA money can generally be used for dental care that treats or prevents disease, such as exams, cleanings, fillings, crowns, dentures and orthodontic care needed for dental health. Purely cosmetic procedures, such as teeth whitening, generally do not qualify. Your FSA administrator has the final list of eligible expenses.
What happens to unused FSA money?
Generally, you must use FSA money within the plan year. Your employer may offer one of two options, but not both, and is not required to offer either:
A carryover. You can carry unused money into the next plan year. For 2026 plan years, the maximum carryover is $680.
A grace period. You get up to two and a half extra months after the plan year ends to use the money.
Anything left after the deadline is forfeited. Your employer or FSA administrator can tell you which option, if any, your plan offers.
Does our office work with my dental insurance?
We are an out-of-network practice. We can help you understand how to use your benefits. You are responsible for amounts your plan does not pay. To learn how out-of-network benefits are usually calculated, read what patients should know about out-of-network dental insurance. If you are planning around retirement or a change in coverage, see retirement and dental insurance.
Planning care before the year ends
If you have not had a checkup this year, or you have treatment you have been putting off, now is a good time to ask about scheduling. New patients start with a comprehensive dental exam. You can reach our Jacksonville office through our contact page or at 904-398-1549.
Sources
Internal Revenue Service. Rev. Proc. 2025-32 (health FSA limit $3,400 and maximum carryover $680 for plan years beginning in 2026). Retrieved October 6, 2026.
Internal Revenue Service. IRS releases tax inflation adjustments for tax year 2026 (IR-2025-103, October 9, 2025). Retrieved October 6, 2026.
HealthCare.gov. Using a Flexible Spending Account (FSA) (grace period of up to 2½ months, or a carryover, but not both). Retrieved October 6, 2026.
Internal Revenue Service. Publication 502, Medical and Dental Expenses (teeth whitening not includible).
About the author. CJ Henley, DMD, is a general dentist in Jacksonville whose practice focuses on cosmetic and restorative dentistry, dental implants and dental care around head and neck cancer. Meet Dr. Henley.
CJ Henley, DMD, PA · 3675 Hendricks Avenue, Jacksonville, FL 32207 · 904-398-1549
Updated October 2026.